NEXIUM 40 mg esomeprazole Powder for solution for injection/infusion

Transcription

1 NEXIUM 40 mg esomeprazole Powder for solution for injection/infusion Qualitative and Quantitative Composition Each vial contains esomeprazole 40 mg. (as sodium salt) Pharmaceutical form Powder for solution for injection/infusion White to off-white porous cake or powder Therapeutic indications Nexium for injection and infusion is indicated as an alternative to oral therapy when oral intake is not appropriate: for gastroesophageal reflux disease in patients with esophagitis and/or severe symptoms of reflux. for healing of gastric ulcers associated with NSAID therapy. Prevention of rebleeding following therapeutic endoscopy for acute bleeding gastric or duodenal ulcers. Posology and method of administration Gastric antisecretory treatment when the oral route is not possible Patients who cannot take oral medication may be treated parenterally with mg once daily. Patients with reflux oesophagitis should be treated with 40 mg once daily. Patients treated symptomatically for reflux disease should be treated with 20 mg once daily. For healing of gastric ulcers associated with NSAID therapy the usual dose is 20 mg once daily. Usually the iv treatment duration is short and transfer to oral treatment should be made as soon as possible. Prevention of rebleeding of gastric and duodenal ulcers Following therapeutic endoscopy for acute bleeding gastric or duodenal ulcers, 80 mg should be administered as a bolus infusion over 30 minutes, followed by a continuous intravenous infusion of 8 mg/h given over 3 days (72 hours). The parenteral treatment period should be followed by oral acid suppression therapy. Method of administration Injection 40 mg dose The reconstituted solution should be given as an intravenous injection over a period of at least 3 minutes. 20 mg dose Half of the reconstituted solution should be given as an intravenous injection over a period of approximately 3 minutes. Any unused solution should be discarded. Infusion 1

2 40 mg dose The reconstituted solution should be given as an intravenous infusion over a period of 10 to 30 minutes. 20 mg dose Half of the reconstituted solution should be given as an intravenous infusion over a period of 10 to 30 minutes. Any unused solution should be discarded. 80 mg bolus dose The reconstituted solution should be given as a continuous intravenous infusion over 30 minutes. 8 mg/h dose The reconstituted solution should be given as a continuous intravenous infusion over a period of 71.5 hours (calculated rate of infusion of 8 mg/h. See section Shelf Life for shelf-life of the reconstituted solution.). Children and adolescents Nexium should not be used in children since no data is available. Impaired renal function Dose adjustment is not required in patients with impaired renal function. Due to limited experience in patients with severe renal insufficiency, such patients should be treated with caution. (See section Pharmacokinetic properties) Impaired hepatic function GERD: Dose adjustment is not required in patients with mild to moderate liver impairment. For patients with severe liver impairment, a maximum daily dose of 20 mg Nexium should not be exceeded. (See section Pharmacokinetic properties) Bleeding ulcers: Dose adjustment is not required in patients with mild to moderate liver impairment. For patients with severe liver impairment, following an initial bolus dose of 80 mg Nexium for infusion, a continuous intravenous infusion dose of 4 mg/h for 71.5 hours may be sufficient (See section Pharmacokinetic properties). Elderly Dose adjustment is not required in the elderly. Contraindications Hypersensitivity to the active substance esomeprazole or to other substituted benzimidazoles or to any of the excipients of this medicinal product. Esomeprazole should not be used concomitantly with nelfinavir (See section Interaction with other medicinal products and other forms of interaction). Special warnings and precautions for use In the presence of any alarm symptom (e.g. significant unintentional weight loss, recurrent vomiting, dysphagia, haematemesis or melaena) and when gastric ulcer is suspected or present, malignancy should be excluded, as treatment with Nexium may alleviate symptoms and delay diagnosis. 2

3 Treatment with proton pump inhibitors may lead to slightly increased risk of gastrointestinal infections such as Salmonella and Campylobacter (See section Pharmacodynamic properties). Co-administration of esomeprazole with atazanavir is not recommended (see section Interaction with other medicinal products and other forms of interaction). If the combination of atazanavir with a proton pump inhibitor is judged unavoidable, close clinical monitoring is recommended in combination with an increase in the dose of atazanavir to 400 mg with 100 mg of ritonavir; esomeprazole 20 mg should not be exceeded. Results from studies in healthy subjects have shown a pharmacokinetic/pharmacodynamic interaction between clopidogrel (300 mg loading dose/75mg daily maintenance dose) and esomeprazole (40 mg p.o. daily) resulting in decreased exposure to the active metabolite of clopidogrel by an average of 40%, and resulting in decreased maximum inhibition of (ADP induced) platelet aggregation by an average of 14%. Based on these data, concomitant use of esomeprazole and clopidogrel should be avoided. See also the Interaction section. Interference with laboratory tests Increased CgA level may interfere with investigations for neuroendocrine tumours. To avoid this interference, esomeprazole treatment should be temporarily stopped for at least five days before CgA measurements. It has been reported that high-dose or long-term PPI therapy may be associated with an increased risk of fractures of the hip, wrist, and spine. However, no causal link has been established. When prescribing proton pump inhibitors, consider whether a lower dose or shorter duration of therapy would adequately treat the patient s condition. Patients at risk for osteoporosis with PPI use should have their bone status managed and should take adequate vitamin D and calcium supplementation. Hypomagnesemia Hypomagnesemia, symptomatic and asymptomatic, has been reported rarely in patients treated with PPIs for at least three months, in most cases after a year of therapy. Serious adverse events include tetany, arrhythmias, and seizures. In most patients, treatment of hypomagnesemia required magnesium replacement and discontinuation of the PPI. For patients expected to be on prolonged treatment or who take PPIs with medications such as digoxin or drugs that may cause hypomagnesemia (e.g., diuretics), health care professionals may consider monitoring magnesium levels prior to initiation of PPI treatment and periodically. Interaction with other medicinal products and other forms of interaction Interaction studies have only been performed in adults. Effects of esomeprazole on the pharmacokinetics of other drugs Medicinal products with ph dependent absorption The decreased intragastric acidity during treatment with esomeprazole might increase or decrease the absorption of drugs if the mechanism of absorption is influenced by gastric 3

4 acidity. In common with the use of other inhibitors of acid secretion or antacids, the absorption of ketoconazole and itraconazole can decrease and the absorption of digoxin can increase during treatment with esomeprazole. Concomitant treatment with omeprazole (20 mg daily) and digoxin in healthy subjects increased the bioavailability of digoxin by 10% (up to 30% in two out of ten subjects). Digoxin toxicity has been rarely reported. However, caution should be exercised when esomeprazole is given at high doses in elderly patients. Therapeutic drug monitoring of digoxin should then be reinforced. Omeprazole has been reported to interact with some protease inhibitors. The clinical importance and the mechanisms behind these reported interactions are not always known. Increased gastric ph during omeprazole treatment may change the absorption of the protease inhibitors. Other possible interaction mechanisms are via inhibition of CYP 2C19. For atazanavir and nelfinavir, decreased serum levels have been reported when given together with omeprazole and concomitant administration is not recommended. Co-administration of omeprazole (40 mg once daily) with atazanavir 300 mg/ritonavir 100 mg to healthy volunteers resulted in a substantial reduction in atazanavir exposure (approximately 75% decrease in AUC, C max and C min ). Increasing the atazanavir dose to 400 mg did not compensate for the impact of omeprazole on atazanavir exposure. The co-administration of omeprazole (20 mg qd) with atazanavir 400 mg/ritonavir 100 mg to healthy volunteers resulted in a decrease of approximately 30% in the atazanavir exposure as compared with the exposure observed with atazanavir 300 mg/ritonavir 100 mg qd without omeprazole 20 mg qd. Co-administration of omeprazole (40 mg qd) reduced mean nelfinavir AUC, C max and C min by % and mean AUC, C max and C min for the pharmacologically active metabolite M8 was reduced by 75-92%. For saquinavir (with concomitant ritonavir), increased serum levels (80-100%) have been reported during concomitant omeprazole treatment (40 mg qd). Treatment with omeprazole 20 mg qd had no effect on the exposure of darunavir (with concomitant ritonavir) and amprenavir (with concomitant ritonavir). Treatment with esomeprazole 20 mg qd had no effect on the exposure of amprenavir (with and without concomitant ritonavir). Treatment with omeprazole 40 mg qd had no effect on the exposure of lopinavir (with concomitant ritonavir). Due to the similar pharmacodynamic effects and pharmacokinetic properties of omeprazole and esomeprazole, concomitant administration with esomeprazole and atazanavir is not recommended and concomitant administration with esomeprazole and nelfinavir is contraindicated. Drugs metabolised by CYP2C19 Esomeprazole inhibits CYP2C19, the major esomeprazole metabolising enzyme. Thus, when esomeprazole is combined with drugs metabolised by CYP2C19, such as diazepam, citalopram, imipramine, clomipramine, phenytoin etc., the plasma concentrations of these drugs may be increased and a dose reduction could be needed. Concomitant oral administration of 30 mg esomeprazole resulted in a 45% decrease in clearance of the CYP2C19 substrate diazepam. Concomitant oral administration of 40 mg esomeprazole and phenytoin resulted in a 13% increase in trough plasma levels of phenytoin in epileptic patients. It is recommended to monitor the plasma concentrations of phenytoin when treatment with esomeprazole is introduced or withdrawn. Omeprazole (40 mg once daily) increased voriconazole (a CYP2C19 substrate) C max and AUC by 15% and 41%, respectively. Concomitant oral administration of 40 mg esomeprazole to warfarin-treated patients in a clinical trial showed that coagulation times were within the accepted range. However, postmarketing of oral esomeprazole, a few isolated cases of elevated INR of clinical significance 4

5 have been reported during concomitant treatment. Monitoring is recommended when initiating and ending concomitant esomeprazole treatment during treatment with warfarin or other coumarin derivatives In healthy volunteers, concomitant oral administration of 40 mg esomeprazole and cisapride resulted in a 32% increase in area under the plasma concentration-time curve (AUC) and a 31% prolongation of elimination half-life (t 1/2 ) but no significant increase in peak plasma levels of cisapride. The slightly prolonged QTc interval observed after administration of cisapride alone, was not further prolonged when cisapride was given in combination with esomeprazole. Esomeprazole has been shown to have no clinically relevant effects on the pharmacokinetics of amoxicillin or quinidine. No in vivo interaction studies have been performed with the high dose iv regimen (80mg+8mg/h). The effect of esomeprazole on drugs metabolised by CYP2C19 may be more pronounced during this regimen, and patients should be monitored closely for adverse effects, during the 3-day i.v. treatment period Results from studies in healthy subjects have shown a pharmacokinetic/pharmacodynamic interaction between clopidogrel (300 mg loading dose/75mg daily maintenance dose) and esomeprazole (40 mg p.o. daily) resulting in decreased exposure to the active metabolite of clopidogrel by an average of 40%, and resulting in decreased maximum inhibition of (ADP induced) platelet aggregation by an average of 14%. It is, however, uncertain to what extent this interaction is clinically important. One prospective, randomized (but incomplete) study (in over 3760 patients comparing placebo with omeprazole 20 mg in patients treated with clopidogrel and ASA) and non-randomized, post-hoc analyses of data from large, prospective, randomized clinical outcome studies (in over patients) did not show any evidence of an increased risk for adverse cardiovascular outcome when clopidogrel and PPIs, including esomeprazole, were given concomitantly. Results from a number of observational studies are inconsistent with regard to increased risk or no increased risk for CV thromboembolic events when clopidogrel is given together with a PPI. When clopidogrel was given together with a fixed dose combination of esomeprazole 20 mg + ASA 81 mg compared to clopidogrel alone in a study in healthy subjects there was a decreased exposure by almost 40% of the active metabolite of clopidogrel. However, the maximum levels of inhibition of (ADP induced) platelet aggregation in these subjects were the same in the clopidogrel and the clopidogrel + the combined (esomeprazole + ASA) product groups, likely due to the concomitant administration of low dose ASA. Effects of other drugs on the pharmacokinetics of esomeprazole Esomeprazole is metabolised by CYP2C19 and CYP3A4. Concomitant oral administration of esomeprazole and a CYP3A4 inhibitor, clarithromycin (500 mg b.i.d.), resulted in a doubling of the exposure (AUC) to esomeprazole. Concomitant administration of esomeprazole and a combined inhibitor of CYP2C19 and CYP3A4 may result in more than doubling of the esomeprazole exposure. The CYP2C19 and CYP3A4 inhibitor voriconazole increased omeprazole AUC by 280%. A dose adjustment of esomeprazole is not regularly required in 5

6 either of these situations. However, dose adjustment should be considered in patients with severe hepatic impairment and if long-term treatment is indicated. Drugs known to induce CYP2C19 or CYP3A4 or both (such as rifampicin and St. John s wort) may lead to decreased esomeprazole serum levels by increasing the esomeprazole metabolism. Pregnancy and lactation For esomeprazole limited data on exposed pregnancies are available. Animal studies with esomeprazole do not indicate direct or indirect harmful effects with respect to embryonal/fetal development. Animal studies with the racemic mixture do not indicate direct or indirect harmful effects with respect to pregnancy, parturition or postnatal development. Caution should be exercised when prescribing Nexium to pregnant women. It is not known whether esomeprazole is excreted in human breast milk. No studies in lactating women have been performed. Therefore Nexium should not be used during breastfeeding. Effects on ability to drive and use machines Nexium is not likely to affect the ability to drive or use machines. Undesirable effects The following adverse drug reactions have been identified or suspected in the clinical trials programme for esomeprazole administered orally or intravenously and post-marketing when administered orally. The reactions are classified according to frequency: very common 1/10; common 1/100 to <1/10; uncommon 1/1000 to <1/100; rare 1/10000 to <1/1000; very rare <1/10000; not known (cannot be estimated from the available data). Blood and lymphatic system disorders Rare: Leukopenia, thrombocytopenia Very rare: Agranulocytosis, pancytopenia Immune system disorders Rare: Hypersensitivity reactions e.g. fever, angioedema and anaphylactic reaction/shock Metabolism and nutrition disorders Uncommon: Peripheral oedema Rare: Hyponatraemia Very rare: Hypomagnesaemia Psychiatric disorders Uncommon: Insomnia Rare: Agitation, confusion, depression Very rare: Aggression, hallucinations Nervous system disorders Common: Headache Uncommon: Dizziness, paraesthesia, somnolence Rare: Taste disturbance 6

7 Eye disorders Uncommon: Blurred vision Ear and labyrinth disorders Uncommon: Vertigo Respiratory, thoracic and mediastinal disorders Rare: Bronchospasm Gastrointestinal disorders Common: Abdominal pain, constipation, diarrhoea, flatulence, nausea/vomiting Uncommon: Dry mouth Rare: Stomatitis, gastrointestinal candidiasis Hepatobiliary disorders Uncommon: Increased liver enzymes Rare: Hepatitis with or without jaundice Very rare: Hepatic failure, encephalopathy in patients with pre-existing liver disease Skin and subcutaneous tissue disorders Common: Administration site reactions* Uncommon: Dermatitis, pruritus, rash, urticaria Rare: Alopecia, photosensitivity Very rare: Erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis (TEN) Musculoskeletal, connective tissue and bone disorders Rare: Arthralgia, myalgia Very rare: Muscular weakness Renal and urinary disorders Very rare: Interstitial nephritis Reproductive system and breast disorders Very rare: Gynaecomastia General disorders and administration site conditions Rare: Malaise, increased sweating *Administration site reactions have mainly been observed in a study with high-dose exposure over 3 days (72 hours). Irreversible visual impairment has been reported in isolated cases of critically ill patients who have received omeprazole (the racemate) intravenous injection, especially at high doses, but no causal relationship has been established. Postmarketing experience Metabolism and Nutritional Disorders: hypomagnesemia 7

8 Overdose There is very limited experience to date with deliberate overdose. The symptoms described in connection with an oral dose of 280 mg were gastrointestinal symptoms and weakness. Single oral doses of 80 mg esomeprazole and intravenous doses of 308mg esomeprazole over 24 hours were uneventful. No specific antidote is known. Esomeprazole is extensively plasma protein bound and is therefore not readily dialyzable. As in any case of overdose, treatment should be symptomatic and general supportive measures should be utilised. PHARMACOLOGICAL PROPERTIES Pharmacodynamic properties Pharmacotherapeutic group: Proton pump inhibitor ATC Code: A02B C05 Esomeprazole is the S-isomer of omeprazole and reduces gastric acid secretion through a specific targeted mechanism of action. It is a specific inhibitor of the acid pump in the parietal cell. Both the R- and S-isomer of omeprazole have similar pharmacodynamic activity. Site and mechanism of action Esomeprazole is a weak base and is concentrated and converted to the active form in the highly acidic environment of the secretory canaliculi of the parietal cell, where it inhibits the enzyme H + K + -ATPase the acid pump and inhibits both basal and stimulated acid secretion. Effect on gastric acid secretion After 5 days of oral dosing with 20 mg and 40 mg of esomeprazole, intragastric ph above 4 was maintained for a mean time of 13 hours and 17 hours, respectively over 24 hours in symptomatic GORD patients. The effect is similar irrespective of whether esomeprazole is administered orally or intravenously. Using AUC as a surrogate parameter for plasma concentration, a relationship between inhibition of acid secretion and exposure has been shown after oral administration of esomeprazole. During intravenous administration of 80 mg esomeprazole as a bolus infusion over 30 minutes followed by a continuous intravenous infusion of 8 mg/h for 23.5 hours, intragastric ph above 4, and ph above 6 was maintained for a mean time of 21 hours, and hours, respectively, over 24 hours in healthy subjects. Therapeutic effects of acid inhibition Healing of reflux esophagitis with esomeprazole 40 mg occurs in approximately 78% of patients after 4 weeks, and in 93% after 8 weeks of oral treatment. In a randomized, double blind, placebo-controlled clinical study, patients with endoscopically confirmed peptic ulcer bleeding characterised as Forrest Ia, Ib, IIa or IIb (9%, 43%, 38% and 10 % respectively) were randomized to receive Nexium solution for infusion (n=375) or placebo (n=389). Following endoscopic haemostasis, patients received either 80 mg esomeprazole as an intravenous infusion over 30 minutes followed by a continuous infusion of 8 mg per hour or placebo for 72 hours. After the initial 72 hour period, all patients received open-label 40 mg oral Nexium for 27 days for acid suppression The occurrence of rebleeding within 3 days was 5.9% in the Nexium treated group compared to 10.3% for the 8

9 placebo group. At 30 days post-treatment, the occurrence of rebleeding in the Nexium treated versus the placebo treated group was 7.7% vs 13.6%. Other effects related to acid inhibition During treatment with antisecretory drugs serum gastrin increases in response to the decreased acid secretion. Chromogranin A (CgA) also increases due to decreased gastric acidity. An increased number of ECL cells possibly related to the increased serum gastrin levels, have been observed in some patients during long term treatment with orally administered esomeprazole. During long-term oral treatment with antisecretory drugs gastric glandular cysts have been reported to occur at a somewhat increased frequency. These changes are a physiological consequence of pronounced inhibition of acid secretion, are benign and appear to be reversible. Decreased gastric acidity due to any means including proton pump inhibitors, increases gastric counts of bacteria normally present in the gastrointestinal tract. Treatment with proton pump inhibitors may lead to slightly increased risk of gastrointestinal infections such as Salmonella and Campylobacter. Pharmacokinetic properties Distribution The apparent volume of distribution at steady state in healthy subjects is approximately 0.22 L/kg body weight. Esomeprazole is 97% plasma protein bound. Metabolism and excretion Esomeprazole is completely metabolised by the cytochrome P450 system (CYP). The major part of the metabolism of esomeprazole is dependent on the polymorphic CYP2C19, responsible for the formation of the hydroxy- and desmethyl metabolites of esomeprazole. The remaining part is dependent on another specific isoform, CYP3A4, responsible for the formation of esomeprazole sulphone, the main metabolite in plasma. The parameters below reflect mainly the pharmacokinetics in individuals with a functional CYP2C19 enzyme, extensive metabolisers. Total plasma clearance is about 17 L/h after a single dose and about 9 L/h after repeated administration. The plasma elimination half-life is about 1.3 hours after repeated once-daily dosing. Total exposure (AUC) increases with repeated administration of esomeprazole. This increase is dose-dependent and results in a non-linear dose-auc relationship after repeated administration. This time - and dose-dependency is due to a decrease of first pass metabolism and systemic clearance probably caused by inhibition of the CYP2C19 enzyme by esomeprazole and/or its sulphone metabolite. Esomeprazole is completely eliminated from plasma between doses with no tendency for accumulation during once-daily administration. Following repeated doses of 40 mg administered as intravenous injections, the mean peak plasma concentration is approx micromol/l. The mean peak plasma concentration after corresponding oral doses is approx. 4.6 micromol/l. A smaller increase (of approx 30%) can be seen in the total exposure after intravenous administration compared to oral administration. 9

10 There is a dose-linear increase in total exposure following intravenous administration of esomeprazole as a 30-minute infusion (40 mg, 80 mg or 120 mg) followed by a continuous infusion (4 mg/h or 8 mg/h) over 23.5 hours. The major metabolites of esomeprazole have no effect on gastric acid secretion. Almost 80% of an oral dose of esomeprazole is excreted as metabolites in the urine, the remainder in the faeces. Less than 1% of the parent drug is found in urine. Special patient populations Approximately 15-20% of the Chinese population lacks a functional CYP2C19 enzyme and is called poor metabolisers. In these individuals the metabolism of esomeprazole is probably mainly catalysed by CYP3A4. After repeated once-daily administration of 40 mg oral esomeprazole, the mean total exposure was approximately 100% higher in poor metabolisers than in subjects with a functional CYP2C19 enzyme (extensive metabolisers). Mean peak plasma concentrations were increased by about 60%. Similar differences have been seen for intravenous administration of esomeprazole. These findings have no implications for the posology of esomeprazole. The metabolism of esomeprazole is not significantly changed in elderly subjects (71-80 years of age). Following a single oral dose of 40 mg esomeprazole the mean total exposure is approximately 30% higher in females than in males. No gender difference is seen after repeated once-daily administration. Similar differences have been observed for intravenous administration of esomeprazole. These findings have no implications for the posology of esomeprazole. The metabolism of esomeprazole in patients with mild to moderate liver dysfunction may be impaired. The metabolic rate is decreased in patients with severe liver dysfunction resulting in a doubling of the total exposure of esomeprazole. Therefore, a maximum dose of 20 mg should not be exceeded in GERD patients with severe dysfunction. For patients with bleeding ulcers and severe liver impairment, following an initial bolus dose of 80 mg, a maximum continuous intravenous infusion dose of 4 mg/h for 71.5 hours may be sufficient. Esomeprazole or its major metabolites do not show any tendency to accumulate with oncedaily dosing. No studies have been performed in patients with decreased renal function. Since the kidney is responsible for the excretion of the metabolites of esomeprazole but not for the elimination of the parent compound, the metabolism of esomeprazole is not expected to be changed in patients with impaired renal function. List of excipients Disodium edetate Sodium hydroxide (for ph adjustment) Incompatibilities This medicinal product should not be used with other medicinal products except those mentioned in section Instructions for use and handling, and disposal (if appropriate). Shelf Life Please refer to expiry date on the outer carton. 10

11 Shelf-life after reconstitution Chemical and physical in-use stability has been demonstrated for 12 hours at 30 C. From a microbiological point of view, the product should be used immediately. Special precautions for storage Store in the original package, in order to protect from light. Vials can however be stored exposed to normal in door light outside the box for up to 24 hours. Do not store above 25 C. Pack Size Please refer to the outer carton for pack size. Instructions for use and handling, and disposal (if appropriate) The reconstitution solution should be inspected visually for particulate matter and discoloration prior to administration. Only clear solution should be used. For single use only. When administering a 20 mg dose only half of the reconstituted solution should be used. Any unused solution should be discarded. Injection A solution for injection is prepared by adding 5 ml of 0.9% sodium chloride for intravenous use to the vial with esomeprazole. The reconstituted solution for injection is clear and colourless to very slightly yellow. The degradation of reconstituted solution is highly ph dependent and the product must therefore only be reconstituted in the specified volume of 0.9% sodium chloride for intravenous use. The reconstituted solution should not be mixed or co-administered in the same infusion set with any other drug. Infusion A solution for infusion is prepared by dissolving the content of one vial with esomeprazole in up to 100 ml 0.9% sodium chloride for intravenous use. The reconstituted solution for infusion is clear and colourless to very slightly yellow. Infusion 80 mg A solution for infusion is prepared by dissolving the content of two vials of esomeprazole 40 mg in up to 100 ml of 0.9% sodium chloride for intravenous use. The degradation of reconstituted solution is highly ph dependent and the product must therefore only be reconstituted in the specified volume of 0.9% sodium chloride for intravenous use. The reconstituted solution should not be mixed or co-administered in the same infusion set with any other drug. The reconstituted solution should be administrated separately from other drugs. Date of revision of the text May 2013 GEL number: GI Nexium is a trade mark of the AstraZeneca group of companies AstraZeneca AstraZeneca AB, Södertälje, Sweden 11